Acute coronary syndrome (main): Difference between revisions

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*Type 3 - Cardiac Death Due to Myocardial Infarction
*Type 3 - Cardiac Death Due to Myocardial Infarction
**suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers
**suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers
*Type 4 -Myocardial Infarction Associated With Revascularization Procedure
*Type 4 - Myocardial Infarction Associated With Revascularization Procedure
**4a: Related to PCI
**4a: Related to PCI
**4b: Related to Stent Thrombosis
**4b: Related to Stent Thrombosis

Revision as of 03:51, 13 November 2015

For risk stratification see ACS - Risk Stratification

Background

Myocardial Infarction types

ACS is three diseases involving the coronary arteries:

  1. ST-Elevation Myocardial Infarction (STEMI) (30%)
  2. Non ST-Elevation Myocardial Infarction (NSTEMI) (25%)
  3. Unstable Angina (38%)

MI Types by Causation[1]

  • Type 1 - Spontaneous Myocardial Infarction
    • atherosclerotic plaque rupture or intraluminal thrombus in one or more of the coronary arteries
  • Type 2 - Myocardial Infarction Secondary to an Ischaemic Imbalance
    • condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand
  • Type 3 - Cardiac Death Due to Myocardial Infarction
    • suffer cardiac death with symptoms suggestive of myocardial ischaemia without elevated biomarkers
  • Type 4 - Myocardial Infarction Associated With Revascularization Procedure
    • 4a: Related to PCI
    • 4b: Related to Stent Thrombosis
  • Type 5 - Myocardial Infarction Related to CABG Procedure

Clinical Features

Risk of ACS

Clinical factors that increase likelihood of ACS/AMI:[2][3]

Clinical factors that decrease likelihood of ACS/AMI:[4]

  • Pleuritic chest pain
  • Positional chest pain
  • Sharp, stabbing chest pain
  • Chest pain reproducible with palpation

Gender differences in ACS

  • Women with ACS:
    • Less likely to be treated with guideline-directed medical therapies[5]
    • Less likely to undergo cardiac catheterization[5]
    • Less likely to receive timely reperfusion therapy[5]
    • More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[5] although some studies have found fewer differences in presentation[6]
  • More likely to delay presentation[5]
  • Men with ACS:
    • More likely to report central chest pain

Factors associated with delayed presentation[5]

  • Female sex
  • Older age
  • Black or Hispanic race
  • Low educational achievement
  • Low socioeconomic status

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Elevated Troponin

True Positive

False (Non-CAD) Positives

Diagnosis

Workup

Evaluation

ACS Anatomical Correlation Chart

Ischemic Changes Location Coronary Artery
STE V1-V3, TWI

Q waves in V1-V3 over time

Septal Septal branch
STE V2-V4 Anterior LAD
STE I, aVL, V5, V6

STD inf leads

Lateral Circumflex
STE I, aVL, V2-6 Anterolateral LAD + circumflex = Left main or 2 critical lesions
STE II, III, aVF

STD in aVL (most common lead to see reciprocal change)

Inferior RCA

STE V1 (only lead looking at RV)
STE III > II (III more R facing)
STE V1 > V2, STE V1 + STD V2

Right ventricle RCA

STD in V1, V2, V3;
R>S in V1
Tall R waves in V1-V3 (Q waves on back of heart) w/ upright TWs

Posterior aka Inferolateral RCA (90%), LCA (10%)
STE avR>V1

Doesn't apply in SVT

Anterolateral Left Main

Treatment

Intensity of treatment should be based on ACS likelihood

Disposition

  • Admit all ACS pts

Prognosis

ACS - Stress Testing

External Links

See Also

References

  1. Third Universal Definition of Myocardial Infarction http://circ.ahajournals.org/content/126/16/2020.full.pdf
  2. Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
  3. Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
  4. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
  6. Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.